Prognosis after the onset of coronary heart disease. An investigation of differences in outcome between the sexes according to initial coronary disease presentation

Abstract

Background: Differences exist between men and women in prognosis after the onset of coronary heart disease (CHD).

Methods and results: All Framingham Heart Study subjects with the onset of clinically apparent coronary disease from 1951 through 1986 were studied to compare prognosis in men and women according to CHD presentation. Coronary disease presentations included angina, coronary insufficiency (unstable angina), recognized myocardial infarction, unrecognized myocardial infarction, and coronary death. Less than 1% of subjects were lost to follow-up for overall mortality. Cox modeling was used to examine the sex differences in outcome for each coronary presentation. New nonfatal coronary disease developed in 750 men (mean age, 63 years) and 583 women (mean age, 67 years). After onset of angina, men were at greater risk than women for myocardial infarction (hazards ratio [HR], 2.20; 95% confidence interval [CI], 1.45 to 3.34) and coronary death (HR, 2.11; 95% CI, 1.32 to 3.36) after adjustment for age and coronary disease risk factors. After a recognized myocardial infarction, there was a trend toward greater risk for overall mortality in women than men after adjustment for age and risk factors (HR, 0.75; 95% CI, 0.53 to 1.08). In contrast, after an unrecognized myocardial infarction, men were at increased risk for death compared with women (HR, 2.01; 95% CI, 1.28 to 3.15).

Conclusions: Women fare at least as poorly as men after recognized myocardial infarction, whereas women have a more favorable outlook than men after the onset of angina or unrecognized myocardial infarction. The favorable outcome in women after angina and unrecognized myocardial infarction is due, in part, to greater misclassification of these coronary events in women than in men.